As artificial intelligence (AI) continues to transform healthcare, AI medical scribing apps are emerging as the newest tools for helping clinicians’ efficiency. Designed to streamline note-taking, these apps promise to free up time for providers, reduce burnout, and improve the accuracy of clinical notes. But while the benefits are clear, there are important legal implications to consider, particularly for the potential role they could play in medical malpractice cases.
Today’s AI scribing software works by ambiently listening to clinical encounters, recording the conversation, and generating a structured note that can be uploaded directly into the electronic health record (EHR). These apps go far beyond simple transcription. They’re designed to extract relevant medical details while ignoring small talk—filtering out the “how’s the family?” chatter to focus on what actually matters to the clinical record.
Most AI scribing apps are HIPAA-compliant, storing encrypted recordings in a secure cloud rather than on local devices. This can be a major asset for clinicians, potentially allowing them to reference the original audio if the AI misses important details or misinterprets patient statements. However, the stored recordings raise important legal questions about data permanence and access, particularly when the accuracy of patient records could come under scrutiny in court.
One critical question is whether audio files created by AI scribing apps could be subpoenaed in medical malpractice lawsuits. Historically, if a dispute arises over what was communicated during a medical encounter, the written medical note has generally served as the only record. This note represents the clinician's interpretation of the conversation—a filtered, medically informed interpretation of the encounter.
An audio file, on the other hand, is an unedited record, which can be compelling evidence, especially if there are discrepancies between the recording and the written notes. Such audio files could be used to corroborate—or challenge—the accuracy of the medical note, potentially influencing the outcome of malpractice cases.
The existence of audio recordings challenges the traditional role of medical notes. Unlike an audio recording, a medical note is a filtered account in which the clinician’s interpretation of patient information plays a large role. This interpretation helps translate the patient’s symptoms into medically relevant information to communicate to other clinicians, such as recording ‘lethargic’ only when clinically significant, versus omitting the word ‘lethargic’ when parents use the word for a child who is babbling, awake, and playing in the room.
Similarly, there have been real-life malpractice cases in which a plaintiff argues that they had reported specific symptoms that the provider neglected to document, leading to a misdiagnosis or delay in treatment. If the existence of a recording confirms the patient’s account, it could be damaging to the defense, raising the stakes for both clinicians and healthcare facilities. Conversely, the audio recording could protect a clinician, substantiating that they addressed all reported concerns appropriately.
There’s also the question of how AI scribing apps affect the dynamic between patients and providers. Knowing that every word is recorded could make patients or clinicians more guarded, potentially detracting from open communication. Patients may be hesitant to discuss sensitive information if they are uncertain about how it will be used or stored. Likewise, clinicians might become more rigid in their documentation and conversational style, aiming to avoid saying anything that could be misinterpreted later.
While transparency is important, so is building trust. It’s worth considering how the presence of a scribing app might shift the tone of a visit—even unintentionally.
Key Takeaways for Clinicians and Legal Teams
As AI scribing software becomes more common, healthcare providers need to understand both the upsides and the legal risks. These tools can support better documentation, reduce errors, and help manage burnout. But they may also introduce new complexities when it comes to medical malpractice claims. As with any emerging technology, AI medical scribing apps should be used with eyes wide open to the balance between convenience, compliance, and liability in a field where accuracy and confidentiality are paramount.